Uterine Fibroid Embolization

Uterine fibroid
embolization (UFE, also known as uterine artery embolization UAE)
is a procedure performed by an interventional radiologist (IR). The technique
involves placing a catheter into the artery and guiding it to the uterus.
The IR then injects small particles of plastic (polyvinyl alcohol or PVA)
into the artery. The PVA blocks the blood supply feeding the fibroids and
this results in embolization. The whole procedure takes about an hour and
you are sedated but awake the entire time.

Within minutes
after the procedure the fibroids begin dying. Generally, (but not always)
there is an overnight stay in the hospital because many women have felt intense
abdominal cramping and pain. Post-procedural pain is usually controlled through
the use of a combination of narcotics but some IRs have started using epidurals
(spinal anesthesia) to block all pelvic region pain for 12 hours or so. Ninety-nine
percent (99%) of the women who undergo this procedure go home after only 1
night in the hospital.

Recovery is 1-2
weeks. Most women are up and around within a couple of days. The majority
return to work after only 1 week of recovery. I returned to work after 6 days
off but probably could have waited and returned after the second week. However,
there was no traumatic surgery to recover from, no hormonal whammies from
having anything "removed", and no psychological stress involved regarding
the removal of the uterus.

Post Embolization Syndrome

Post embolization
syndrome is something that I and many other women have experienced with
uterine fibroid embolization. Although most of the immediate side effects
or symptoms that are the result of this procedure do not last long,
post embolization syndrome can take up to 6 weeks to go away.

So what
is this syndrome? It consists mostly of menopause-type symptoms, such
as hot flashes, a general sense of not feeling well, and nausea. It
can be downright annoying and troublesome.

As the
fibroids die, toxins are released into the blood stream that can cause
these symptoms. While the majority of women recover from these symptoms
within 1 to 2 weeks post procedure, they have been known to last as
long as 6 weeks.

CRITICAL
NOTE:
If any of the symptoms you experience include an ever increasing amount
of pain or a rise in fever that does not subside within a short period
of time, contact your physician immediately for further evaluation.

Ideal Patient

The ideal patient
for this procedure meets four basic requirements:

they have
fibroids

the fibroids
are symptomatic

there is no
cancer

future pregnancies
are not desired.

Although some
interventional radiologists have additional requirements, it is not proven
that any of these requirements have a basis in scientific data collected thus
far. For instance, one interventional radiologist states that he doesn't accept
patients that have a fibroid uterus that has grown above the navel in size
-- any fibroid uterus roughly larger than a 16-20 week pregnancy is unacceptable.
In his experience, the percentage of shrinkage from this size of fibroid uterus
is not significant enough to warrant doing the procedure. However, his experience
may include fewer than a dozen patients with fibroids of this size. Collectively,
the data simply hasn't been reviewed yet for efficacy of UFE in relationship
to size of fibroid uterus. Who knows whether or not his exclusionary patient
selection process is valid? Maybe it is. Maybe it isn't.

Still other IRs
are turning women away because they are 50 years of age or more. Since the
average age of menopause is 51, they've somehow determined that doing nothing
and simply waiting out menopause is a more appropriate course to take for
these women. Nevermind that 51 is the average age of menopause.
(The women in my family didn't hit menopause until they were nearly 60
or so.) Nevermind that the women are bleeding like there's
no tomorrow.

Someone needs
to tell these docs that the word AVERAGE means there's a span of difference
with a low and a high and the numerically totaled and divided middle point
is the AVERAGE. Geez.

The average
age of menopause is 51, give or take 1 to 15 years. Capiche?

Come on guys.
Don't make me draw a bell curve here. Appropriate testing can be done that
would determine a little more accurately where a woman is on the spectrum
from peri-menopause to post-menopause.

Some additional
concerns and considerations might include:

a) the presence
of submucosal fibroids which can or should be resected hysteroscopically
b) the presence of pedunculated subserosal fibroids more effectively treated
by removing them via myomectomy.

UFE treats all
uterine fibroids at the same time and is, therefore, an extremely effective,
all encompassing treatment option. However, submucosal fibroids not removed
before UFE may infarct once they die and cause the uterus to attempt to get
rid of the fibroid. If the fibroid is too large for the uterus to expel, serious
infection could result. This can be extremely painful and potentially dangerous.
It is important for women with submucosal fibroids to discuss this possibility
with their gynecologist and determine how to handle the care of their submucosal
fibroids before the UFE.

Pedunculated
subserosal fibroids may also infarct and break off from the uterus once they
necrotize. This has been known to create a temporarily painful condition treatable
with pain medication but, so far, no additional problems have been encountered.
Only more time will tell us whether or not this is a complication with additional
concerns.

Success, Failures, and Complications

Doctors are currently
tracking success and failure of this procedure by two different standards:
technical failure and clinical failure. Knowing the difference
between these two kinds of failures will give you a better understanding of
what the success statistics actually mean to you when you read them. In addition,
complications can occur during the procedure which result in injury,
a less than desired outcome, or unanticipated results.

Technical Failure Rates

Technical
failures
currently occur 1-2% of the time and are primarily related to the following
items.

skill of interventional
radiologist

abnormalities
of the uterine artery

shared blood
flow from a single uterine artery and ovarian artery (with both feeding
the fibroids) -- a blood flow situation called anastomoses

any number
of additional odd circumstances that present themselves during the procedure.

Clinical Failure Rates

Clinical failure
rates are another cup of tea entirely. Typically these have nothing to do
with the interventional radiologist and his/her embolization of your artery
but rather your own physical response to the embolization. If the embolization
is a technical success but the symptoms the fibroids were causing are not
significantly or satisfactorily reduced post-UFE, then this is considered
a clinical failure. For example, if the fibroids don't shrink "enough"
or excessive bleeding doesn't subside then the UFE would be considered a clinical
failure.

You won't see
the term "clinical failure rates" in medical literature, however.
Instead, you'll see numbers that tout the statistics of how many women report
"shrinkage" or reduced bleeding. Like this:

"...80-90%
of all women undergoing UFE report...".

Sort of "reverse
statistics" to get you to focus on the positive side of things. Here's
the reality: 80-90% success rates invert to equate to 10-20% failure. Yep.
10-20% clinical failure rate. (Some IRs report 10-15% and others 15-20%
-- statistics haven't really been pooled across the board yet with the results
published.) The numbers look different to you now, don't they?

Here's something
the numbers won't tell you:

Even
with high clinical failure rates, women (even those who sustained clinical
failure) are reporting that they would STILL choose UFE over hysterectomy
or even myomectomy if they had to do it all over again.

Why is that?
Why do women who've had "less than success" with their UFE still
perceive it to be a better option? From my own personal experience, I would
say it's because even though the procedure wasn't a complete success,
it was enough to restore life back to an acceptable level of existence. And,
at minimal surgical (technical) risk to me -- particularly compared to hysterectomy
or even myomectomy.

Complications

Complications
currently occur 1-2% of the time. Less than 1 in 200 women will acquire
an infection that requires an immediate hysterectomy. Other items that
contribute to the complication rate are:

Finding that
the woman has only a single uterine artery and the ovarian artery is
feeding the fibroids (or, the uterine artery is feeding the ovary--the
blood can actually flow in either direction). Doctors do one of two things
in this case:

a) they partially
embolize the ovarian artery (which may cause premature menopause) or

b) they go
ahead and embolize the uterine artery and that's all (the fibroids continue
to receive blood from the ovarian artery so the overall amount of "shrinkage"
to the fibroids is reduced significantly--or, if the blood is actually
flowing to the ovaries from the uterus, they've just shut off its blood
supply--instant menopause).

Misembolization

Misembolization
is typically referred to as "non target embolization" in
medical literature. I prefer the term "misembolization"
but several IRs have pointed out that this implies there's been a
"mis-take" when, in fact, there was simply an embolization
of something non targeted and it could have been a mistake or simply
materials going awry. It's a finer point to make and differentiate--one
I think that is completely lost on most women. Hey--something got
embolized that shouldn't have. End of story. Misembolization.

Complete misembolization
of the ovarian artery. Results in menopause.

Misembolization
of other areas that were not "targeted." Areas that would, oh
for example let's say, impact your buttocks or legs. None have been reported
to date--but it has occurred. What doctors do and what doctors "officially"
report are not always the same thing. Effects of misembolization are generally
temporary but can be quite serious, depending on what, exactly, the doctor
misembolized.

Femoral
hematoma. A deep bruising of the puncture site (for arterial catheterization)
in the groin.

Death.
While there have been no deaths reported in the United States from UFE,
there has been one death in England and possibly a second death in Italy
associated with UFE. Statistically, this represents a tiny fraction of the
number of women (over 6,500) who have undergone this procedure worldwide.
UPDATE

Miscellaneous
side effects.
Doctors are still figuring these out as they are so infrequent that only
time and long range data collection will give them a more complete list.
Please ask your interventional radiologist for a more complete list of complication
possibilities during your initial appointment.

One of the side effects of UFE may well be some level of sexual dysfunction.
(You can read about my own experience with this in My
Journal.) If you are a woman who experiences uterine contractions or
internal pelvic orgasms during sex and the blood flow to the cervix is altered
because of uterine artery embolization, you may experience a loss
of those contractions or internal orgasms. Although most women are reluctant
to discuss this with their physician, I am aware of a number of cases (besides
my own) where loss of internal orgasms and/or uterine contractions has,
in fact, occurred. Several of us are nearing the one year mark post-UFE
and have shown no signs of improvement. Clitoral orgasms and intensity of
feeling in the vagina have also been reported as less intense with some
women post UFE but in all cases that I am aware of to date these have returned
to "normal" within 3 or 4 months. Until more women choose to openly
discuss the issue of sex with their physicians both pre and post procedure
we will not know how often sexual dysfunction actually occurs as a result
of this procedure.

History of UFE

There have been
thousands of UFEs performed over the last 8 years for the specific treatment
of uterine fibroids. Prior to that, uterine artery embolization (UAE)
was reserved for women who began hemorrhaging following childbirth or after
pelvic surgery (such as myomectomy).

UAE is a procedure
that has been around for about 20 years and medical literature has detailed
it as an effective means of stopping uncontrollable bleeding since 1979 or
so. (Although the SCVIR recently changed the name of this procedure to represent
it's specific treatment application for uterine fibroids, technically UAE
and UFE are the same procedure.)

About 10 years
ago (1989), an ob/gyn in Paris, France (Dr. Jacques-Henri Ravina) read the
medical literature indicating that UAE was an effective means of stopping
uncontrollable bleeding and decided to start using UAE PRE-myomectomy to cut
down on the bleeding that patients would experience during the procedure.
He was quite surprised to start finding women canceling out on their myomectomies.
They no longer needed the myomectomy because their bleeding had subsided and
their fibroids had actually begun to shrink.

From there, it
took another 7 years before the procedure was introduced into the United States
by Dr. Scott Goodwin at the UCLA Medical Center. Since introducing this procedure
in 1996, there have been over 4,000 uterine fibroid embolizations performed
in the United States. Nonetheless, it has been an uphill struggle to get gynecologists
to recognize this promising procedure in the United States because it directly
cuts into the revenue they currently receive from performing so many hysterectomies.

On Gynecologists and Money. . .

Many a
gynecologist has written to me indicating that they do not believe that
gynecologists are refusing to refer for this procedure based on loss
of revenue from not performing a hysterectomy. They are wholly unconvincing.
Sorry guys. A woman's reproductive organs are clearly on the auction
block of medicine in this country and the billion dollar HRT industry
is standing in line right behind you encouraging you on. It is most
definitely about money. Get busy doing some REAL research on sparing
the uterus with uterine fibroid treatments and you might be a little
more believable in your protests. No matter how many refinements of
a hysterectomy you come up with, you need to understand that it
is still a hysterectomy! Apparently that is a point missed by
many gynecologists.

The Doctors and Web Links

The following
web links will lead you into a rather fascinating world of interventional
radiology. You'll find an entirely different "breed" of doctors
than the gynecologists you're probably accustomed to and you will be quite
surprised at the information that many of them are choosing to present to
women in an effort to ensure that you truly do understand all of the choices
available for treatment of your uterine fibroids. For firsthand information
about my own experiences with this choice, you can, of course, read My
Journal. In addition, for ongoing discussions among women on this topic,
please join us at the uterinefibroids chat group.

Comprehensive
uterine fibroids treatment website brought to you by the Interventional
Radiologist responsible for introducing Uterine Artery Embolization into
the United States for the treatment of fibroids.

Home
page of Dr. Bruce McLucas: Detailed description of uterine embolization
and Dr. McLucas' special requirements for referral. (Note:
Dr. Scott Goodwin is not a staff member of Dr. McLucas' medical
firm. Although they have published papers together and worked together
in the past, Dr. McLucas now refers patients to an outpatient clinic for
UAE in Beverly Hills where he has purchased equipment and hired an IR
to perform UAE on all of his referred patients at that clinic.)
Author's note: As a former patient of Dr. McLucas, I am providing
this link for informational purposes only. Under no circumstances can
I, personally, recommend Dr. McLucas.

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